Provider Demographics
NPI:1629559034
Name:KOREN, MELISSA NICHOLE (BCBA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:NICHOLE
Last Name:KOREN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:NICHOLE
Other - Last Name:ELKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:901 O ST STE C
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-5789
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 O ST STE C
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-5789
Practice Address - Country:US
Practice Address - Phone:707-497-9335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-18-30115103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst